— 生理適應 · HARD · MCQ —
一位 45 歲高血壓病史病患，突發劇烈頭痛與視覺障礙，血壓 220/130 mmHg。護理師應優先採取何項措施？
A 45-year-old client with a history of hypertension reports a sudden onset of severe headache and visual disturbances. The blood pressure is 220/130 mmHg. Which action is the priority?
- APrepare the client for a stat CT scan準備病人進行緊急電腦斷層掃描
- BElevate the head of the bed to 45 degrees✓ 正解將床頭抬高至 45 度
- CAdminister oral antihypertensive medication給予口服抗高血壓藥物
- DObtain an EKG to assess for ischemia進行心電圖檢查以評估缺血情形
— Explanation · 中文詳解 —
此為高血壓危象（Hypertensive Crisis），優先採取半坐臥姿（45度）可降低顱內壓並減輕心臟後負荷。口服藥物吸收太慢，應給予靜脈輸注藥物（如 Nitroprusside）；CT 掃描雖重要，但需先穩定生命徵象；EKG 可隨後進行，但非當下穩定病況的首要措施。
Elevating the head of the bed to 45 degrees is the priority action to reduce intracranial pressure and cardiac workload in a hypertensive crisis. While imaging and IV medications are necessary, stabilizing the patient's position helps mitigate immediate risks associated with severely elevated blood pressure.
✦ 台美臨床差異
美國護理師依 protocol 可在監測下給予 IV 藥物；台灣通常需醫師親自評估後開立給藥醫囑。